Pain Treatment

CENTRAL TECHNIQUES

Used primarily in patients with intractable pain from malignancy

STEREOTACTIC THALAMOTOMY: The spinoreticular system appears largely responsible for the unpleasant aspects of pain sensation. Stereotactic obliteration of the spinoreticular relay nuclei in the thalamus (page 370) may help patients with intractable pain from malignancy involving the head, neck or brachial plexus, sites where other methods of pain control are limited.

DEEP BRAIN STIMULATION: Stimulation .. _ , .

„. , , , , . , . radiofrequency heat lesion in a of implanted electrodes inserted in the • „ • , „ , ,

... stereotactically implanted electrode periventricular grey matter, sensory , . . . ,

, , , , inserted into the midbrain reticular relay nucleus of the thalamus or *■■._.•■«_«-

. , __________formation may help patients with head internal capsule may produce ------✓ ,

,. .. ... / and neck malignancy, pain relief in patients with head or neck malignancy.

If successful, a radiocontrolled stimulator is implanted \ ^

subcutaneously.

HYPOPHYSECTOMY: By transphenoidal excision or with radioactive yttrium may help pain from metastatic deposits. The mechanism of relief remains uncertain; this is not merely due to tumour regression.

PERCUTANEOUS ANTEROLATERAL ' CORDOTOMY: A percutaneous radiofrequency heat lesion of the spinothalamic tract now replaces open cordotomy. This produces pain relief in 90% of patients in the contralateral limbs. It is usually applicable in malignant states where simple methods of pain control have failed. Risks (ipisilateral limb weakness and respiratory difficulties) are small.

MYELOTOMY: Exposure of the cord and division of the decussating pain fibres produces pain relief on a temporary basis, restricting use to patients with terminal malignancy.

DORSAL ROOT ENTRY ZONE LESIONS

Following cord exposure, multiple radiofrequency heat lesions of the dorsal root entry zone are produced with a hand held electrode. This may help deafferentation pain, i.e. brachial plexus avulsion, but ipsilateral leg weakness is a major complication.

MYELOTOMY: Exposure of the cord and division of the decussating pain fibres produces pain relief on a temporary basis, restricting use to patients with terminal malignancy.

DORSAL COLUMN STIMULATION: Stimulation of electrodes inserted percutaneously into the epidural space may benefit patients with chronic pain, unresponsive to non-invasive techniques. A trial with exteriorised electrodes permits evaluation, prior to implanting a radiocontrolled stimulator.

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